Patient Safety in Primary Care: Conceptual Meanings to the Health Care Team and Patients

Alden Yuanhong Lai, PhD; Christina T. Yuan, PhD; Jill A. Marsteller, PhD; Susan M. Hannum, PhD; Elyse C. Lasser, MS; JaAlah-Ai Heughan, MS; Tyler Oberlander, BA; Zackary D. Berger, MD; Ayse P. Gurses, PhD; Hadi Kharrazi, MD, PhD; Samantha I. Pitts, MD; Sarah H. Scholle, PhD; Sydney M. Dy, MD


J Am Board Fam Med. 2020;33(5):754-764. 

In This Article

Abstract and Introduction


Introduction: Patient safety in primary care is an emerging priority, and experts have highlighted medications, diagnoses, transitions, referrals, and testing as key safety domains. This study aimed to (1) describe how frontline clinicians, administrators, and staff conceptualize patient safety in primary care; and (2) compare and contrast these conceptual meanings from the patient's perspective.

Methods: We conducted interviews with 101 frontline clinicians, administrators and staff, and focus groups with 65 adult patients at 10 patient-centered medical homes. We used thematic analysis to approach coding.

Results: Findings indicate that frontline personnel conceptualized patient safety more in terms of work functions, which reflect the grouping of tasks or responsibilities to guide how care is being delivered. Frontline personnel and patients conceptualized patient safety in largely consistent ways.

Discussion: Function-based conceptualizations of patient safety in primary care may better reflect frontline personnel and patients' experiences than domain-based conceptualizations, which are favored by experts.


Improving patient safety can not only avert preventable deaths but also reduce morbidity, costs, and distress for patients as well as health care professionals.[1,2] Since the Institute of Medicine published "To Err is Human",[3] patient safety efforts have proliferated; although, they have focused more on the inpatient setting than its ambulatory counterpart.[4] Yet, 23 times more people receive services in primary care than in hospitals in the United States yearly.[5,6] Expert consensus highlights medications, diagnosis, transitions, referrals, and testing as key domains in primary care.[4,7,8] Although some of these domains overlap with the inpatient setting, primary care faces additional challenges that may create safety concerns: (1) there is a heavier reliance on patients for disease management; (2) clinical encounters are typically short and episodic; (3) fragmentation exists among electronic health record systems; and (4) practices are more sensitive to changes in size, financing, leadership, and culture.[4] These characteristics warrant the need to explore patient safety in primary care, especially given our increasing need for health services and limited knowledge of safety issues in this setting.[9–11]

Previous research on safety in primary care has examined the epidemiology of medication errors,[12,13] error reporting tools,[14] and perceptions of safety culture.[15,16] A distinct way of contributing to this increasingly important area is to investigate what patient safety in primary care means to those on the frontlines delivering care as well as the patients receiving it. This investigation is useful because, first, clarifying conceptual meanings is often a foundational step for addressing burgeoning topics in the health sciences.[17–19] Second, identifying the meanings generated can help us understand, predict, and improve the actions taken by frontline personnel and patients.[20–22] Third, patient safety research in primary care has tended to focus on the perspectives of either professionals or patients, without efforts to examine them simultaneously.[23–25] By systematically eliciting the meanings from a representation of not only professionals but also administrators, staff, and patients, we can include a wider range of conceptualizations and identify elements that are important to, and how they are different across, stakeholder groups. Such findings can generate potential research directions for scholars as well as preliminary ways for managers to think about the design, implementation, and evaluation of patient safety interventions in primary care.

Our primary research aim was to elucidate the conceptual meanings of patient safety among frontline clinicians, administrators, staff, and patients in the primary care setting. Second, we compared and contrasted the meanings to clinicians, administrators, and staff with those to patients to ascertain the degree of alignment.